Monday, July 10, 2006

Today I saw a patient I haven't seen in four months. The last time I saw him, I ordered some bloodwork because he has hypertension. And one of the things I discovered in that bloodwork was diabetes. Which is a good catch; hypertension plus diabetes is a deadly combination, and requires careful management.

Problem is, I didn't catch it. I signed off on the bloodwork and had it filed. So he's been walking around untreated for the last four months.

Another confession. Last month, I saw a patient I had been treating for chronic back pain. At his previous visit, I'd started him on a pain reliever we sometimes use when anti-inflammatories aren't cutting it but we're nervous about going to opioids. This medication worked very well for him; he was quite pleased, and wanted a refill.

Problem is, I had overlooked the fact that this patient had a contraindication to starting this medication: a seizure disorder. I don't know how I overlooked this; it's his ONLY OTHER PROBLEM BESIDES BACK PAIN. I nervously asked him, "Have you had any problems with seizures?"

"Funny you should ask," he replied. "I've had two seizures since I saw you last, after not having any for two years."

You might be thinking right now, wow, DoctorMama is one of those BAD doctors. Why should I listen to anything she says? And I sometimes feel that way too.

I can tell you that I graduated with honors from a good medical school and I trained in a top-notch residency program. I got excellent board scores, and I keep up to date. I teach (and learn from) medical students and residents.

None of these things guarantees that I'm a good doctor, of course.

I can tell you that patients like me, and recommend me to their friends and family. No one has ever sued me (yet). I've never killed anyone, or caused them irreparable harm that I know of. My patients' blood pressures and blood sugars are better than the national norm, even though their socioeconomic status is well below average.

None of these things guarantees that I'm a good doctor, either.

And none of these things kept me from making those errors.

I know I don't make a lot of mistakes, and I know that everyone makes some. But I'd rather make none. Yet I don't know how this can be achieved.

Looking at the first case, there is a system meant to keep me from making such errors: abnormal results are flagged with an asterisk on the lab sheet. Thing is, every abnormal result is flagged, even ones that clinically make no difference. I sign off "abnormal" results as normal all the time. The only system that differentiates the abnormals that matter from the ones that don't is my fallible brain.

In the second case—the guy with seizures—there are a couple of places that the contraindication might have been spotted. First is my PDA; I often look up medications on the electronic database, and under this medication it clearly says "caution if seizure history." Thing is, I look up only the medications I'm unsure about or unfamiliar with. Which category does not include this particular medication. I KNOW you have to use caution if there's a seizure history; I just didn't THINK about it at the time. And if I were to look up every single medication I prescribe, I couldn't possibly see the number of patients I do (which isn't all that high to begin with). The second place this mistake could have been caught is at the pharmacy; the computer there might have flagged this medication as a problem, given that the patient was also filling prescriptions for anticonvulsants. And perhaps it did, but you've seen the printouts from pharmacies—they're pages long, and include every possible contraindication and side effect. Who can take those seriously?

The patients themselves could have helped prevent these mistakes. The first patient never called to ask about his results; if he had, it would likely have prodded me to take extra care when signing off—though again, no guarantee—and the second patient could have asked if the new medication would interfere with his seizure medicine. But neither patient is the type to do that, and besides, that's not their job. It's my job.

Bottom line is, I dropped the ball, twice.

In neither instance did anything terrible happen. The first patient doesn't take his blood pressure medicines, and wasn't very interested when I told him that he has diabetes. (I did tell him that I had missed it on the last bloodwork; he wasn't very interested in that, either.) He may surprise me and do a better job controlling his diabetes than he has controlling his pressure, but a delay of a few months is not going to make a difference anyway. The second patient didn't hurt himself when he had his seizures, and he doesn't drive. (When I told him of my mistake, he was just upset that he couldn't keep taking the pain reliever. I prescribed him opiates.)

Some doctors are resentful of systems designed to keep them from making mistakes (and worse, of patients or family members who question them). I'm not. It's really scary to have someone's health or life depending on my imperfect mind, and I wish I didn't have to fly without a net so much of the time.

31 comments:

You've sold yourself short, Doctor Mama, in stating you're not a good doctor. You're correct that a good medical school or residency program really doesn't guarantee anything...but your ability to identify your fallibility elevates you above so many of your peers who can't (or won't) do the same (yes, I fall into that category...sigh). Chalk this up under "experiences", use it as as teaching moment for those residents and students, and keep up the good work.

It’s funny, I’m [procrastinating from] studying for the bar exam & was just reviewing med mal stuff – I’d love to hear more of your thoughts on it. I’m personally very wary when people start railing about how litigious patients are putting doctors out of business – I don’t doubt that there are a lot of bullshit claims out there, but much of the drastic increase in malpractice insurance (& all other insurance for that matter) can be attributable to shady business dealings by insurance companies that have nothing to do with actual claims (like playing the stock market with our premiums & losing). Then there’s the whole debacle with HMOs, exploding caseloads, etc. (of which I am sure you are intimately familiar). Anyway, it seems that when legislatures start putting laws into place to curb malpractice claims, they generally focus on procedure, such as shortening statutes of limitations or capping awards, rather than substance, such as modifying the standards that are actually applied in determining whether the mistakeis malpractice (standards that are rather high—more or less the doctor at her best). My theory is that its easier to put procedural hurdles in place—which ultimately affect all claims, from the most meritorious to the most frivolous—because when you start looking at the actual cases, it’s clear that one probably would want to provide those patients some recovery. But on the other hand, it seems so extreme to hold doctors (or anyone for that matter) to their ultimate best for every action they take—that’s just not realistic.

Regardless, like artemis said, just the fact that you are willing to think about & address these issues frankly is part of what makes you obviously a fabulous doctor.

I think you're being overly hard on yourself. You say it's not a patient's job to check their results or ask about medication combinations. Okay, maybe it isn't but from a patient's point of view, it makes very good sense to do so. Of course, some doctors don't welcome patient questions in this respect.

As a doctor you have enormous responsibility and many patients.It's understandable how something like this can happen.

The patient has only their own meds., their own results to think about. If I get given a new medication, I always ask aboutother medications, existing health conditions. Some think I'm a pain in the a*** for doing so, no doubt, but, in the end, I'm the one swallowing the tablet and mistakes have been made (a wrongly given beta blocker as an inpatient soon wised me up on this issue!)

We have a system here where if you don't hear from your doctor with your results, you can assume all is clear. I've had things missed in this way and now I never assume anything but will follow up when I next have an appointment.

Meh. As long as none of your patients are currently pulling cotton balls (er, "cotton-ball-like objects") out of two-week old incisions you're okay in my book. And amen to the props on admission of fallibility--my doctor is STILL trying to convince me that there's no way I had any cotton balls or cotton-ball-like objects in my abdomen, or that if I did HE didn't leave them there. Only problem is, this was my only abdominal surgery ever...kind of like when your roommate says THEY didn't eat your ice cream, but really who else could it have been? I'm not trying to sue him for it or anything. People make mistakes. But for crap's sake, how hard is it to say "geez, I'm sorry, how gross?" I like your approach MUCH better.

i hope the guy who got the opoid prescription also got some tips on stool softeners. ;)

i've been a dentist for 25 years. so far no complaints and no law suits.

i think it's to do with active listening, sincerely caring, explanations and not rushing. i don't comprehend how any dentist can treat 3 patients at the same time. multitasking doesn't work. and people are not cows in the milking shed, although it's rather unfortunate that many people don't seem to realize this.

..........none of us can possibly know everything all the time about everybody, every disease and every medication.

a doctor friend of mine told me one day, if you feel pressured to come up with an answer, just tell "the patient that you are going to think about it. people love it when you think about them."and they do. and it works. because sometimes it takes a bit of time to come up with the solution to a problem.

I think the flaw is in our medical system- its one of the most antiquated businesses in existence. The IOM has been all over the medical errors issue and while progress is being made, its turtle slow. In the computer/Internet/wi-fi era, there really is no excuse not to have pharmacies linked to medical records linked to flags re: serious contraindications. Its not rocket science, but it requires money and systemic coordination, which apparently is too much.

So yeah, I think you are too hard on yourself and there needs to be more focus on systemic change to reduce the risk of errors.

It was refreshing for me, as a pharmacist, to hear a doctor admit to being fallible. Although, my first thought when you talked about the patient with seizure disorders, was why his pharmacist didn't catch it. However, we both know how many problems there are in the systems.

I'm very curious, are you familiar with the Institute for Safe Medication Practices (www.ismp.org). Great resource, great organization. And not just because they employ me!

Can you let your nurses be one level of screening for you? I know I (an RN, soon to be a nurse practitioner) often flag things for my doctors who might not look at them a second time otherwise (and in oncology, we definitely see TONS of "normal abnormals").

The amount of paperwork that flies across doctors' desks is incredible - I honestly don't know how more things don't get missed. For labs, even routine ones, two sets of eyes are better than one. Even if the second set is much less trained than yours.

This is an incredibly brave post. One of your best qualities is to meet things head on and not flinch from unpleasant truths. However, I join the chorus in saying you are being way too hard on yourself. As you said, neither of these put your patients in any real danger. At the same time I can understand why you would find it hard to forgive yourself, given how much you care. All of this makes you a fantastic doctor.I just hope you suck as a labor predictor.

Patients (and their advocates, in an applicable situation) are your partners regarding their care. I understand that you're not blaming the patients you mention for not catching what they could regarding the two issues, but I also feel that these are adults you're treating, and it's your responsibility to help them, not parent them.

Wow, for me, that was really good information about the seizure disorder thing. I would be interested to know the name of the pain med. My son has petit mal epilepsy, and takes Lamictal. When he was prescribed a drug for something else, the pharmacist acted like I was being stupid for asking about interactions/exacerbation of seizures, etc. but after struggling for a year to get it under control, we can't afford to have more seizures. I was irritated that he was so condescending. There are many ways to catch errors, and I feel that patients have to advocate too, because NO ONE is perfect, and EVERYONE makes mistakes...don't feel bad.

I second (or third, or twentieth) everyone who said that your awareness and acknowledgement of your own falliability makes you a much better practitioner than an absence of mistakes would - anyone who claims to be mistake-free, especially in a highly-demanding, highly-stressful profession, especially when working in a healthcare system which is deeply flawed in ways - well, that person is either deluding themselves or their patients.

Must say, though, that I am grateful that MY mistakes can, at worst, temporarily inconvenience an attorney or two. I am plagued by guilt and self-doubt enough as is without having people's lives depend on me!

On the meds . . . ideally the docs would catch contraindications, but in the end isn't part of pharmacist's purpose to catch these things? I worked for a couple IV therapy companies and the pharmacists I worked with would've slit thier wrists if they'd dispensed that drug combination. Really. They were super-anal perfectionist types and they would flip out if a box of supplies was packed messily-- I really don't even want to contemplate if they missed a contraindication. It's not a criticism of them-- if they were here, every one of them would tell you that this is exactly the reason they spent all those years in college-- to know down to the molecule which chemicals do what and how. I hope you called and ripped them a new one (really, you should-- 'cause as a doc you get to press "1" and get directly to the pharmacy, without going through the whole list or prompts, etc. You go to the front of the line!)

Personally, I have HUGE HUGE respect for someone who takes responsibility for their actions when they could just pretend it never happened. Integrity= major bonus points, and you've shown you've got integrity to spare.

Unless you are a true believer, no one is omniscient or omnipotent. The only one who doesn't make mistakes is the one who does nothing. The safety nets you refer to are illusory, no one has figured a way to legislate or ensure perfection. The best you can hope for is to take your best shot, and if you succeed, know where your self-esteem and hope comes from in future similar situations. If you you fail, know that you never finish learning. Living does not come with any guarantees, for anyone.

Ugh. This is why I prefer to use a pharmacist that is an actual pharmacist and not a counter-jockey at a chain store. :) I remember being a kid, and having my pharmacist catch errors and take extra time to talk to us about the different issues that medications could have, etc.

Doctors are great, but they're human. It's nice having an extra layer of precaution in place at the pharmacists. :)

DoctorMama, I don't know how many people expect Dr's to be perfect, it certaibly is not a logical expectation. For me, the fact that you told both these patients that you made a mistake makes all the difference in the world. I don't need a doctor to be perfect, but I do need one to be straight and honest with me. Honest about me and honest about themselves. that's my 2 cents, anyway.

Admitting mistakes to your patients up front will, of course, go a long way toward preventing anyone from ever wanting to sue you for malpractice. It's the docs who won't apologize, won't own up to it, and pass the buck who get sued—clinical skills and keen attention are crucial, of course, but so is not being an asshole.

As a fellow physician, I so hear you. I NEVER want to be tired, distracted, forgetful, etc, anything that would leave me open to make an error. But I'm human, and I have...fortunately nothing serious (along the lines of filing lab tests as well). I agree with the other posters--openness and honesty with patients is paramount. However, patients ARE partners in their healthcare as well. Anyway, excuse the length. You're human. We are trained to ignore are human needs for sleep, for mental rest, sometimes for food, and with that comes difficulty accepting that we can be fallible (at least for me). And there can be such serious consequences from what we do. All we can do is our best, and be honest, and look for systems to check and double check.

like you, in my nursing practice I hate it when I miss something. Like you also, I graduated with honors from one of the best nursing programs in the state but like you said, it doesn't mean we don't make mistakes. Thank goodness we have those safeguards set up to catch things we sometimes might miss. This was a great entry. I appreciate your transparency. IMHO, it is what makes you a good doctor.

I firmly believe that most Americans spend more time researching their next car purchase than they do their own healthcare, and it appalls me. Any competent adult patient should be ashamed to not do the barest bit of due diligence when they're prescribed a med, or at least read the freaking paperwork the pharmacy staples to the bag. ASK the doc. ASK the pharmacist. USE the internet, do something.

I did medical abstracting at LocalClinic when the purchased EPIC (yet another electronic medical record program) and it has contradindication info with all the meds that are in the system, so *ideally* it will flag a bad combo. But it doesn't always work. That's where the trifecta of doc, patient, and pharmacist comes in handy. If, that is, the patient takes some freaking responsibility for their own health.

If my doc had the balls to admit to me that she'd made a mistake (and she did), I'd respect her a lot more than I do. And I'd still be in her service. But she didn't, so I'm not. You do your patients a great honor to admit when you've dropped the ball and I hope they realize that.

You're clearly a great doc. But I'm still not convinced about this running business.

I think we all know and accept that docs make mistakes. We just hope it won't be with us. Or lifethreatening....

On malpractice and insurance companies -- I saw a doc for a physical and he never even had me get undressed. Looked in my eyes, took my BP told me to eat better and get more excercise. I got a whopping bill which I refused to pay until they could send me paperwork proving they did the tests they said they did and the results of the physical. It went to a collection agency and I told the guy I suspected the whole practice was an insurance scam and if he wanted to press it, I'd call the authorities. Never heard from them again.

And that was a doctor who was recommended to us when we moved here!

Then there's my OB/GYN who said I couldn't possibly have had a miscarriage b/c I didn't go to the emergency room but I knew I had. I was furious she insisted on handing me that hope and I had to sit with it for days until I was proven right.

There are all kinds of doctors. The best are smart, and try hard, and are honest, and listen. Gee, sounds like you Dr. Mama!

As I get ready to start as an attending in 2 weeks, you come out with this story to keep me on my toes. I hope I can learn to be as good as a physician as you are! I too want to be a good physician, that my patients and staff like me. But I definitely want to be thought of as one with integrity! I will strive to be like you MamaDoc!

I have great empathy. I too am in a profession where I am often operating without a safety net and I fear making a mistake. Of course, I am human and I make mistakes. It's not an easy thing to live with.

Any human is going to have a non-zero failure rate. I think that's something that we as a society just haven't admitted about people we put in positions where they have to make life or death decisions (doctors, policemen, soldiers, etc.). I think the solutions are to put safety nets in place (but not silly ones like flagging abnormal results that you have to ignore; that's like having red lights that you have to ignore in order to drive). But, in the end, we have to accept that sometimes there will be mistakes, and just try to mitigate the effects of the mistakes.

bjps: I am an official flake who makes mistakes like you're describing all the time (so much that I would have been a negligent, or a compuslive crazy doctor). It's one of the reasons I pat myself on the back repeatedly for having decided not to go to medical school, and having chosen something where my decisions are rarely critical.

As just a plain ol' person who has recently stumbled across your blog, I thank you for your honesty. It is refreshing to hear a doctor humble enough to admit overlooking a thing or two. I nearly died after the birth of my second child because of something my OB/GYN missed, but would never own up to. So I do appreciate your honesty and your willingness to admit that you are, in fact, human and can sometimes make mistakes. Thank you!